Naturalistic Decision Making and the Practice of Health Care

2018 ◽  
Vol 12 (3) ◽  
pp. 178-193 ◽  
Author(s):  
Paul R. Falzer
Keyword(s):  
Health Care ◽  
Decision Making ◽  
Best Practices ◽  
Clinical Decision Making ◽  
Resistance To Change ◽  
Care Practice ◽  
Evidence Based ◽  
Naturalistic Decision Making ◽  
Late 20Th Century ◽  
Care Community

A recent essay in this journal identified health care as a fertile domain for extending the reach of naturalistic decision making (NDM). It targeted the “best practices regimen,” a host of initiatives begun in the late 20th century that address problems in service delivery, skyrocketing costs, and impediments in transforming products of basic science into effective treatments. Of particular importance are efforts to base treatment decisions on empirical research findings and to gauge the quality of decisions by their conformance to evidence-based practices. The challenges that the essay identified and the ways of addressing these challenges are well known in the health care community. They have had limited impact owing to several factors, including how advocates of the best practices regimen envision clinical decision making and their tendency to equate the exercise of skill with resistance to change. This paper describes the regimen’s concept of decision making and its principles and deficiencies. It also identifies a conundrum: oversimplification prevents complexity from being recognized; as a result, evidence-based recommendations frequently have unforeseeable and deleterious consequences. The paper proposes that NDM is well positioned to address these problems and make a valuable contribution to health care practice. It illustrates NDM-based theories and concepts with a research example and describes their ability to address complex issues that arise in treating chronic illnesses.

HEALTH TECHNOLOGY ASSESSMENT AND CLINICAL DECISION MAKING:

1999 ◽  
Vol 15 (3) ◽  
pp. 585-592 ◽  
Author(s):  
Alicia Granados
Keyword(s):  
Health Care ◽  
Decision Making ◽  
Health Technology Assessment ◽  
Case Studies ◽  
Technology Assessment ◽  
Clinical Decision Making ◽  
Clinical Decision ◽  
Health Technology ◽  
Evidence Based ◽  
Systematic Process

This paper examines the rationality of the concepts underlying evidence—based medicineand health technology assessment (HTA), which are part of a new current aimed at promoting the use of the results of scientific studies for decision making in health care. It describes the different approaches and purposes of this worldwide movement, in relation to clinical decision making, through a summarized set of specific HTA case studies from Catalonia, Spain. The examples illustrate how the systematic process of HTA can help in several types of uncertainties related to clinical decision making.

scholarly journals Engaging Multidisciplinary Stakeholders to Drive Shared Decision-Making in Oncology

2018 ◽  
Vol 34 (1) ◽  
pp. 29-31 ◽  
Author(s):  
Gabrielle Rocque ◽  
Ellen Miller-Sonnet ◽  
Alan Balch ◽  
Carrie Stricker ◽  
Josh Seidman ◽  
...  
Keyword(s):  
Health Care ◽  
Decision Making ◽  
Best Practices ◽  
Shared Decision Making ◽  
Best Practice ◽  
Care Delivery ◽  
Evidence Based ◽  
Shared Decision ◽  
Oncology Practice ◽  
Development And Validation

Although recognized as best practice, regular integration of shared decision-making (SDM) approaches between patients and oncologists remains an elusive goal. It is clear that usable, feasible, and practical tools are needed to drive increased SDM in oncology. To address this goal, we convened a multidisciplinary collaborative inclusive of experts across the health-care delivery ecosystem to identify key principles in designing and testing processes to promote SDM in routine oncology practice. In this commentary, we describe 3 best practices for addressing challenges associated with implementing SDM that emerged from a multidisciplinary collaborative: (1) engagement of diverse stakeholders who have interest in SDM, (2) development and validation of an evidence-based SDM tool grounded within an established conceptual framework, and (3) development of the necessary roadmap and consideration of the infrastructure needed for engendering patient engagement in decision-making. We believe these 3 principles are critical to the success of creating SDM tools to be utilized both within and outside of clinical practice. We are optimistic that shared use across settings will support adoption of this tool and overcome barriers to implementing SDM within busy clinical workflows. Ultimately, we hope that this work will offer new perspectives on what is important to patients and provide an important impetus for leveraging patient preferences and values in decision-making.

The ‘Number Needed to Treat’ and the ‘Adjusted NNT’ in Health Care Decision-Making

1998 ◽  
Vol 3 (1) ◽  
pp. 44-49 ◽  
Author(s):  
Jack Dowie
Keyword(s):  
Health Care ◽  
Decision Making ◽  
Evidence Based Medicine ◽  
Clinical Decision Making ◽  
Treatment Options ◽  
Clinical Decision ◽  
Population Based ◽  
Number Needed To Treat ◽  
Evidence Based ◽  
Based Medicine

Within ‘evidence-based medicine and health care’ the ‘number needed to treat’ (NNT) has been promoted as the most clinically useful measure of the effectiveness of interventions as established by research. Is the NNT, in either its simple or adjusted form, ‘easily understood’, ‘intuitively meaningful’, ‘clinically useful’ and likely to bring about the substantial improvements in patient care and public health envisaged by those who recommend its use? The key evidence against the NNT is the consistent format effect revealed in studies that present respondents with mathematically-equivalent statements regarding trial results. Problems of understanding aside, trying to overcome the limitations of the simple (major adverse event) NNT by adding an equivalent measure for harm (‘number needed to harm’ NNH) means the NNT loses its key claim to be a single yardstick. Integration of the NNT and NNH, and attempts to take into account the wider consequences of treatment options, can be attempted by either a ‘clinical judgement’ or an analytical route. The former means abandoning the explicit and rigorous transparency urged in evidence-based medicine. The attempt to produce an ‘adjusted’ NNT by an analytical approach has succeeded, but the procedure involves carrying out a prior decision analysis. The calculation of an adjusted NNT from that analysis is a redundant extra step, the only action necessary being comparison of the results for each option and determination of the optimal one. The adjusted NNT has no role in clinical decision-making, defined as requiring patient utilities, because the latter are measurable only on an interval scale and cannot be transformed into a ratio measure (which the adjusted NNT is implied to be). In any case, the NNT always represents the intrusion of population-based reasoning into clinical decision-making.

scholarly journals An Evidence-Based Health Care Knowledge Integration System: Assessment Protocol (Preprint)

2018 ◽  
Author(s):  
Véronique Nabelsi ◽  
Sylvain Croteau
Keyword(s):  
Health Care ◽  
Decision Making ◽  
Clinical Practice ◽  
Clinical Decision Making ◽  
Evidence Based ◽  
Clinical Practices ◽  
Assessment Protocol ◽  
Decision Making Processes ◽  
Services Sociaux ◽  
Medical Recommendations

BACKGROUND The rapid advancements in health care can make it difficult for general physicians and specialists alike to keep their knowledge up to date. In medicine today, there are deficiencies in the application of knowledge translation (KT) in clinical practice. Some medical procedures are not required, and therefore, no value is added to the patient’s care. These unnecessary procedures increase pressures on the health care system’s resources, reduce the quality of care, and expose the patients to stress and to other potential risks. KT tools and better access to medical recommendations can lead to improvements in physicians’ decision-making processes depending on the patient’s specific clinical situation. These tools can provide the physicians with the available options and promote an efficient professional practice. Software for the Evolution of Knowledge in MEDicine (SEKMED) is a technological solution providing access to high-quality evidence, based on just-in-time principles, in the application of medical recommendations for clinical decision-making processes recognized by community members, accreditation bodies, the recommendations from medical specialty societies made available through campaigns such as Choosing Wisely, and different standards or accreditive bodies. OBJECTIVE The main objective of this protocol is to assess the usefulness of the SEKMED platform used within a real working clinical practice, specifically the Centre intégré de santé et des services sociaux de l’Outaouais in Quebec, Canada. To achieve our main objective, 20 emergency physicians from the Hull and Gatineau Hospitals participate in the project as well as 20 patient care unit physicians from the Hull Hospital. In addition, 10 external students or residents studying family medicine from McGill University will also participate in our study. METHODS The project is divided into 4 phases: (1) orientation; (2) data synthesis; (3) develop and validate the recommendations; and (4) implement, monitor, and update the recommendations. These phases will enable us to meet our 6 specific research objectives that aim to measure the integration of recommendations in clinical practices, the before and after improvements in practices, the value attributed by physicians to recommendations, the user’s platform experience, the educational benefits according to medical students, and the organizational benefits according to stakeholders. The knowledge gained during each phase will be applied on an iterative and continuous basis to all other phases over a period of 2 years. RESULTS This project was funded in April 2018 by the Fonds de soutien à l’innovation en santé et en services sociaux for 24 months. Ethics approval has been attained, the study began in June 2018, the data collection will be complete at the end of December 2019, and the data analysis will start in winter 2020. Both major city hospitals in the Outaouais region, Quebec, Canada, have agreed to participate in the project. CONCLUSIONS If results show preliminary efficacy and usability of the system, a large-scale implementation will be conducted. INTERNATIONAL REGISTERED REPOR DERR1-10.2196/11754

Evidence-Based Medicine, Best Practices, Transductive Models, and Naturalistic Decision Making: Commentary on Paul R. Falzer, Naturalistic Decision Making and the Practice of Health Care

2018 ◽  
Vol 12 (3) ◽  
pp. 194-197 ◽  
Author(s):  
Robert Brian Haynes
Keyword(s):  
Health Care ◽  
Decision Making ◽  
Evidence Based Medicine ◽  
Health Research ◽  
Interdisciplinary Collaboration ◽  
Effective Means ◽  
Evidence Based ◽  
Care Providers ◽  
Naturalistic Decision Making ◽  
Based Medicine

Expert and informed decision making is an essential process in all of health care. Evidence-Based Medicine (EBM) purports to support and enhance this process by the timely infusion of high-quality, pertinent evidence from health research, tailored as closely as possible to the individual and their health problem. Doing so is not an easy task for many reasons, beginning with imperfections and incompleteness in the evidence and ending with the complexities of the dual decision making required by individuals and their care providers. EBM needs a lot of help supporting decision-making processes and welcomes further interdisciplinary collaboration. The “conformist principle,” “best practice regimens,” and “transductive models” should not be considered as barriers to such collaboration: These are not part of EBM. Rather, EBM has always seen evidence from health research as but one of many inputs to decision making by providers and patients. An overarching problem for collaboration to address is understanding the decision-making process well enough to develop effective means to bolster it, so that people are consistently offered the current best options for their problems in a way that fits their circumstances and that they can understand and judge.

Industrial Conceptualization of Health Care Versus the Naturalistic Decision-Making Paradigm: Work as Imagined Versus Work as Done

2018 ◽  
Vol 12 (3) ◽  
pp. 222-226 ◽  
Author(s):  
Ken Catchpole ◽  
Myrtede Alfred
Keyword(s):  
Health Care ◽  
Decision Making ◽  
Clinical Reasoning ◽  
Clinical Decision Making ◽  
Clinical Decision Support Systems ◽  
Clinical Work ◽  
Clinical Decision ◽  
Naturalistic Decision Making ◽  
Weak Part ◽  
Context Specific

Quality and safety concerns in health care over the past 20 years precipitated the need to move beyond the traditional view of health care as an artisanal process toward a sociotechnical systems view of performance. The adoption of industrial approaches placed a greater emphasis on standardization of processes and outcomes, often treating humans as the “weak” part of the system rather than valuing their role in holding together complex, opaque, and unpredictable clinical systems. Although some health care tasks can be modeled linearly, others are much more complex. Efforts to reduce variation in clinical reasoning through evidence-based practices have proven problematic by failing to provide a means for context-specific adaptation or to account for the complex and adaptive nature of clinical work. We argue that the current, highly empirical approach to clinical decision making reflects clinical reasoning “as imagined,” whereas the application of the naturalistic decision-making (NDM) paradigm can help reveal clinical reasoning “as done.” This approach will have benefits for improving the conditions for diagnosis; the design of acute, time-pressured clinical work; the identification of deteriorating patients; the development of clinical decision support systems; and many more clinical tasks. Health care seems ready to accept NDM approaches.

Integrating Evidence-Based Practice in Athletic Training

2017 ◽  
pp. 1368-1378
Author(s):  
Brittany A. Vorndran ◽  
Michelle Lee D'Abundo
Keyword(s):  
Health Care ◽  
Decision Making ◽  
Continuing Education ◽  
Athletic Training ◽  
Health Care Professional ◽  
Clinical Decision Making ◽  
Evidence Based Practice ◽  
Athletic Trainers ◽  
Clinical Decision ◽  
Evidence Based

Evidence-based practice (EBP) involves a health care professional using his or her own knowledge, the current research published, and the needs of the patient to make the best clinical decision. This has been a hot topic in many different branches of healthcare and recently athletic trainers have begun to embrace its importance. In December of 2015, athletic trainers (ATs) will need to have completed ten of their fifty continuing education units (CEUs) in EBP to maintain certification. While ATs recognize the significance of implementing EBP into clinical decision making, there are many barriers slowing the change. This chapter includes information about how EBP is currently being used by athletic training clinicians and educators, the barriers ATs perceive to using EBP, the importance of using EBP, and managing the transition needed to successfully adopt the use of EBP.

EBM: Rationalist Fever Dreams

2018 ◽  
Vol 12 (3) ◽  
pp. 227-230 ◽  
Author(s):  
Devorah Klein ◽  
David Woods ◽  
Gary Klein ◽  
Shawna Perry
Keyword(s):  
Health Care ◽  
Decision Making ◽  
Evidence Based Medicine ◽  
Best Practice ◽  
Decision Makers ◽  
Evidence Based ◽  
Naturalistic Decision Making ◽  
The Face ◽  
Based Medicine

In 2016, we examined the connection between naturalistic decision making and the trend toward best practice compliance; we used evidence-based medicine (EBM) in health care as an exemplar. Paul Falzer’s lead paper in this issue describes the historical underpinnings of how and why EBM came into vogue in health care. Falzer also highlights the epistemological rationale for EBM. Falzer’s article, like our own, questions the rationale of EBM and reflects on ways that naturalistic decision making can support expertise in the face of attempts to standardize practice and emphasize compliance. Our objectives in this commentary are first to explain the inherent limits of procedural approaches and second to examine ways to help decision makers become more adaptive.

Debates in Dysphagia Management: How Do You Use Evidence-Based Practice in Your Dysphagia Patient Care?

2011 ◽  
Vol 20 (4) ◽  
pp. 121-123
Author(s):  
Jeri A. Logemann
Keyword(s):  
Decision Making ◽  
Patient Care ◽  
Clinical Outcomes ◽  
Clinical Judgment ◽  
Clinical Decision Making ◽  
Evidence Based Practice ◽  
Clinical Decision ◽  
Evidence Based ◽  
Clinical Method ◽  
Do So

Evidence-based practice requires astute clinicians to blend our best clinical judgment with the best available external evidence and the patient's own values and expectations. Sometimes, we value one more than another during clinical decision-making, though it is never wise to do so, and sometimes other factors that we are unaware of produce unanticipated clinical outcomes. Sometimes, we feel very strongly about one clinical method or another, and hopefully that belief is founded in evidence. Some beliefs, however, are not founded in evidence. The sound use of evidence is the best way to navigate the debates within our field of practice.

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